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xPssC` a? <br /> Please pilint ort Forth designed for use on elite(12-pft)M wtttei? 7 l cAr SC PP W 10/10/2017 Form ,OMB No.2050-0039 <br /> UNIFORM NAZAROOUS 1.Generator ID Number 2.Pam 1 aF 3.Emergency Response Phone a Maniresi�t �t �g N 1 r 6 3 F L E <br /> WASTE MANIFEST CAL 0 0 0 3 5 91 0 2 1 (800)483-3719 11 <br /> 5.&M <br /> NamM M"Address Generala s Site Address(it different than mailing address) <br /> 2526 W.Washininon Street 221±w W-A,ha%dwnn Qfram* <br /> Stockton.CA 95203 Stockton,CA 95203 <br /> GeneratnrsPhona:(2081320,3714 A1THJesselewis <br /> b.Transporter 1 CDmvnyl!Na U.S.EPA ID Number <br /> 7,TransilhirleMorrony Name U.S.EPA ID Number <br /> 8.Designated FacTiy Name and SAe Address U.S.EPA ID Number <br /> Clean Harbors B=onwillow LLC u n u S o G`o f-`vii n <br /> 2500 West Lokem Road <br /> ButtomNillow.CA 93206 <br /> Faclit s Phone: l66i1762-6200 <br /> 9a. 9b-U.S.DOT Description(including Paper Shipping Name,Hazard Class,ID Number, 10.Contairrers 11.Total 12 Unit 13,Waste Codes <br /> HM and Pecidng Group(t eny)) No. Type Ouantity Wt.Nat. <br /> 11. <br /> UN1759,CORROSIVE SOLIDS.N.O.S.,(ARSENIC,CHROMIUML 571 <br /> Lx S,PG III,(BOTTOM ASH) / <br /> LU 2- ` <br /> w <br /> f'J <br /> 3 <br /> 4. <br /> i4.Special Handling Insisuotions and Additional Information <br /> 1-C113463ao ZMCV#154 <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labaleftlararded,and are in all respect in proper condition for transport according to eppicebie international and rational govammenfal regulations.If export shipment and I am the Primary <br /> Exporter,l cer ify that the contents of this censlgnmem conform to the temrs of the attached EPA Acknowledgrrim of Consent. <br /> I oer*that the waste minimizatlm statement idenfed in 40 CFR 262.27(s)fid I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> alarW07W Month V" eat <br /> Internalion�Shipm s <br /> ❑Impot b U.S. Export from U.S. Pat.1entrAll. <br /> TranspDrter signature ft aVom only): Dane leaving U.S.: <br /> 17 Transporter Acknowledgment of R"ptof Materials <br /> Tran er 1 Prinled/Typed Name , Ignalure llkriffi Day ear <br /> rrmsporter 2 Prinledll Nona: 5"alute Martin U" "ar <br /> 18.Discrepancy rr'' <br /> t8a.Discrepancy IrMicafon Space 0 Quantity I_ 7 Type Residue ❑PsrBal Rejection Dull Rejection <br /> MenBosi Reference Namur: <br /> 18b Alternate Fararily(orGenaratco U S.EPA 10 Number <br /> U <br /> LL f�tilt s Phone: <br /> W 18c.Signatureof Allernate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> H19.Hazardous Waste Report Management Method Codes(i e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1 - T- <br /> 20. <br /> 4. <br /> H132 <br /> Designated Fadlily pruner or Operator.Certfficadon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PtI;WTyped Name ignak" oar <br /> J;�Z 1611 <br /> EPA Form 8740.22(Rev. 3-05) Previous editions are obsolete. DE IGNA 0 FACILITY TO DESTINATION STATE(IF REQUIRED) � <br /> Ofarr Harbors has the appropriate permits for and will accept the waste the$erferaar iSr s lipping. <br />